Background

Floppy eyelid syndrome (FES) was initially described by Culbertson and Ostler in 1981.
[1] It had not been recognized as a specific entity prior to this. The syndrome was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids associated with a variable chronic papillary conjunctivitis of the upper palpebral conjunctiva.

FES, because its symptoms are common to other disease processes, often is not diagnosed at the onset of symptoms. Several unsuccessful trials of artificial tears, vasoconstrictors, topical steroids, nonsteroidal anti-inflammatory drops, or antibiotics may already have taken place before the correct diagnosis is made. Although FES has been reported in nonobese patients, it is seen more frequently in patients who are obese. The condition often is associated with obstructive sleep apnea (OSA).
[2, 3, 4, 5, 6, 7]

Patients with OSA experience episodic apnea and hypopnea as a consequence of intermittent obstruction of the upper airway. When these patients sleep on their backs, a collapse of the pharynx occurs during inspiration, resulting in loud snoring and eventual apnea, which causes the patient to awaken. OSA eventually can lead to systemic or pulmonary hypertension, congestive heart failure, and cardiac arrhythmia. OSA is associated with other serious ocular disorders, such as glaucoma, ischemic optic neuropathy, and papilledema secondary to increased intracranial pressure. Treatment of OSA can reduce intracranial pressure and secondary papilledema.

Patients with FES usually present with a long history of unilateral or bilateral ocular irritation and discharge with either a preexisting diagnosis of OSA or a history of snoring.

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Pathophysiology

Although tarsal collagen appears normal in patients with FES, several histopathologic studies using special stains, immunohistochemistry, and electron microscopy have demonstrated a significant decrease in tarsal elastin.
[8, 9, 10] The rubbery consistency and laxity of the tarsus may be related to the decrease in elastin. Eyelid laxity allows upper eyelid eversion on inadvertently rubbing the eye or lateral stretching of the lid through contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the conjunctiva.

Etiology

Patients who sleep on one side more than the other side tend to have more severe changes on that side. This finding suggests mechanical injury as the primary cause of the papillary conjunctivitis. In many cases of FES, there is a history of loud snoring or a diagnosis of OSA, which requires the patient to sleep on one side or in a prone position with the face in the pillow. Use of an eye shield to protect the eyelids during sleep often can improve the patient’s signs and symptoms.

FES has been associated with keratoconus, which also suggests mechanical irritation from eye rubbing as a contributing factor.
[12] Others have postulated that the cause of the chronic conjunctivitis is poor apposition of the lax upper eyelid to the globe with inadequate spreading of the tear film.
[13] This condition leads to corneal and conjunctival compromise, rather than direct mechanical irritation. Meibomian gland dysfunction and atrophy can be found in association with FES.
[14]

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Epidemiology

FES is uncommon but underrecognized. It is most commonly diagnosed among middle-aged patients (40-50 years), though it has been reported in patients aged 25-80 years.
[13] The incidence of FES is slightly higher in men than in women.
[12, 13] Although most reported cases have involved white patients, there is probably no racial predilection.

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Prognosis

A medical and surgical approach to managing FES is most often successful in alleviating the patient’s symptoms.

OSA is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension and, ultimately, congestive cardiomyopathy together with cardiac arrhythmia risk. Patients with OSA may complain of morning headaches and daytime somnolence, which may result in poor work performance and an increased risk of automobile accidents.
[15]

Corneal erosions secondary to nocturnal eyelid eversion can result in corneal ulceration and scarring that can lead to permanent decreased vision. Chronic conjunctivitis, punctate keratopathy, and corneal neovascularization may result in contact lens intolerance.

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Patient Education

The following items should be discussed with the patient:

Significance of sleeping with the face against the pillow

Connection between rubbing eyes, keratoconus, and FES

Possibility of associated OSA and, if warranted, the need for further tests to evaluate for this condition

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Jorge G Camara, MD Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine